Abacavir/lamivudine plus darunavir/ritonavir in routine clinical practice: a multicentre experience in antiretroviral therapy-naive and -experienced patients.

OBJECTIVES: To present clinical experience with a regimen including abacavir/lamivudine + darunavir/ritonavir in a cohort of HIV-1-infected patients. METHODS: A retrospective, multicentre cohort study, including all consecutive adult HIV-1-infected patients who started abacavir/lamivudine + darunavir/ritonavir from April 2008 to December 2010 and had at least one follow-up visit. The primary endpoint was HIV-1 viral load (VL) <40 copies/mL at week 48. RESULTS: One hundred and eighty-three patients (42 naive and 141 experienced) from 19 hospitals in Spain were studied. The median follow-up was 26.7 (0.5-58.6) months, 79.8% were men, the median age was 47.1 (21.4-80.5) years, 26.2% had AIDS and 38.8% were positive for hepatitis C virus. At baseline, the median CD4 count was 246 cells/mm(3) in naive patients and 393 cells/mm(3) in experienced patients and the median VL was 4.80 and <1.59 log copies/mL, respectively. At week 48, 81.8% of naive patients and 84.2% of experienced patients receiving the regimen reached a VL <40 copies/mL, whereas at 96 weeks this occurred in 90.5% and 92.8%, respectively. CD4 cell count increases at 48 and 96 weeks were +176.5 and +283.5 cells/mm(3) in naive patients and +74.9 and +93 cells/mm(3) in experienced patients, respectively. Overall, 86 (47%) patients discontinued the study regimen, in many cases possibly related to non-medical reasons, such as drug switches to reduce cost or changes in address due to economic constraints. Three patients died of causes unrelated to therapy and 19 (10.4%) discontinued the regimen due to adverse events. CONCLUSIONS: In our cohort, abacavir/lamivudine + darunavir/ritonavir was safe, well tolerated and achieved high rates of virological suppression. In a proportion of patients, discontinuation of this effective regimen was possibly due to non-medical reasons.

Inequalities in HIV disease management and progression in migrants from Latin America and sub-Saharan Africa living in Spain.

OBJECTIVES: The objective of the study was to analyse key HIV-related outcomes in migrants originating from Latin America and the Spanish-speaking Caribbean (LAC) or sub-Saharan Africa (SSA) living in Spain compared with native Spaniards (NSP). METHODS: The Cohort of the Spanish AIDS Research Network (CoRIS) is an open, prospective, multicentre cohort of antiretroviral-naïve patients representing 13 of the 17 Spanish regions. The study period was 2004-2010. Multivariate logistic or Fine and Gray regression models were fitted as appropriate to estimate the adjusted effect of region of origin on the different outcomes. RESULTS: Of the 6811 subjects in CoRIS, 6278 were NSP (74.2%), LAC (19.4%) or SSA (6.4%). For these patients, the follow-up time was 15870 person-years. Compared with NSP, SSA and LAC under 35 years of age had a higher risk of delayed diagnosis [odds ratio (OR) 2.0 (95% confidence interval (CI) 1.5-2.8) and OR 1.7 (95% CI 1.4-2.1), respectively], as did LAC aged 35-50 years [OR 1.3 (95% CI 1.0-1.6)]. There were no major differences in time to antiretroviral therapy (ART) requirement or initiation. SSA exhibited a poorer immunological and virological response [hazard ratio (HR) [corrected] 0.8 (95% CI 0.7-1.0) and HR [corrected] 0.7 (95% CI 0.6-0.9), respectively], while no difference was found for LAC. SSA and LAC showed an increased risk of AIDS for ages between 35 and 50 years [HR 2.0 (95% CI 1.1-3.7) and HR [corrected] 1.6 (95% CI 1.1-2.4), respectively], which was attributable to a higher incidence of tuberculosis. However, no statistically significant differences were observed in mortality. CONCLUSIONS: Migrants experience a disproportionate diagnostic delay, but no meaningful inequalities were identified regarding initiation of treatment after diagnosis. A poorer virological and immunological response was observed in SSA. Migrants had an increased risk of AIDS, which was mainly attributable to tuberculosis.

Subretinal abscess due to nocardia in an immunosuppressed patient: a case report.

Systemic nocardiosis is a rarely occurring pathology, but its hematogenous spread across the eye is even less likely to occur, with only a few recorded cases. Therefore, it is not usually taken into account when a subretinal abscess is being considered for a diagnosis. However, when confronting a case with a history of immunosupression and pulmonary disease, the examination of the ocular fundus may be a very successful approach. With such aim we introduce the case of a 45-year-old immunosupressed male, without a history of pulmonary disease, whose subretinal mass evolution is accordant with an abscess. In the end, being etiologically diagnosed by means of a vitrectomy, it was concluded that the abscess was due to an infection of nocardia cyriacigeorgica, an emergent pathogen. Thus the aforementioned case is to be considered in the present study, along others, in order to shed more light on a disease which may not be readily diagnosed on account of its infrequency.

Vertebral osteomyelitis after spine instrumentation surgery: risk factors and management.

BACKGROUND: Vertebral osteomyelitis after spine instrumentation surgery (pVOM) is a rare complication. Most cases of infection occur early after surgery that involve skin and soft tissue and can be managed with debridement, antibiotics, and implant retention (DAIR). AIM: To identify pVOM risk factors and evaluate management strategies. METHODS: From a multicentre cohort of deep infection after spine instrumentation (IASI) cases (2010-2016), pVOM cases were compared with those without vertebral involvement. Early and late infections were defined (<60 days and >60 days after surgery, respectively). Multivariate analysis was used to explore risk factors. FINDINGS: Among 410 IASI cases, 19 (4.6%) presented with pVOM, ranging from 2% (7/347) in early to 19.1% (12/63) in late IASIs. After multivariate analysis, age (adjusted odds ratio (aOR): 1.10; 95% confidence interval (CI): 1.03-1.18), interbody fusion (aOR: 6.96; 95% CI: 2-24.18) and coagulase-negative staphylococci (CoNS) infection (aOR: 3.83; 95% CI: 1.01-14.53) remained independent risk factors for pVOM. Cases with pVOM had worse prognoses than those without (failure rate; 26.3% vs 10.8%; P = 0.038). Material removal was the preferred strategy (57.9%), mainly in early cases, without better outcomes (failure rate; 33.3% vs 50% compared with DAIR). Late cases managed with removal had greater success compared with DAIR (failure rate; 0% vs 40%; P = 0.067). CONCLUSION: Risk factors for pVOM are old age, use of interbody fusion devices and CoNS aetiology. Although the diagnosis leads to a worse prognosis, material withdrawn should be reserved for late cases or when spinal fusion is achieved.

Economic burden of recurrent Clostridioides difficile infection in adults admitted to Spanish hospitals. A multicentre retrospective observational study.

OBJECTIVE: Clostridioides difficile infection (CDI) is associated with increased hospital stays and mortality and a high likelihood of rehospitalization, leading to increased health resource use and costs. The objective was to estimate the economic burden of recurrent CDI (rCDI). METHODS: Observational, retrospective study carried out in six hospitals. Adults aged ≥18 years with ≥1 confirmed diagnosis (primary or secondary) of rCDI between January 2010 and May 2018 were included. rCDI-related resource use included days of hospital stay (emergency room, ward, isolation and ICU), tests and treatments. For patients with primary diagnosis of rCDI, the complete hospital stay was attributed to rCDI. When diagnosis of rCDI was secondary, hospital stay attributed to rCDI was estimated using 1:1 propensity score matching as the difference in hospital stay compared to controls. Controls were hospitalizations without CDI recorded in the Spanish National Hospital Discharge Database. The cost was calculated by multiplying the natural resource units by the unit cost. Costs (euros) were updated to 2019. RESULTS: We included 282 rCDI episodes (188 as primary diagnosis): 66.31% of patients were aged ≥65 years and 57.80% were female. The mean hospital stay (SD) was 17.18 (23.27) days: 86.17% of rCDI episodes were isolated for a mean (SD) of 10.30 (9.97) days. The total mean cost (95%-CI) per episode was €10,877 (9,499-12,777), of which the hospital stay accounted for 92.56. CONCLUSIONS: There is high cost and resource use associated with rCDI, highlighting the importance of preventing rCDI to the Spanish National Health System.

Suppressive antibiotic therapy in prosthetic joint infections: a multicentre cohort study.

OBJECTIVES: The aim was to describe the effectiveness of suppressive antibiotic treatment (SAT) in routine clinical practice when used in situations in which removal of a prosthetic implant is considered essential for the eradication of an infection, and it cannot be performed. METHODS: This was a descriptive retrospective and multicentre cohort study of prosthetic joint infection (PJI) cases managed with SAT. SAT was considered to have failed if a fistula appeared or persisted, if debridement was necessary, if the prosthesis was removed due to persistence of the infection or if uncontrolled symptoms were present. RESULTS: In total, 302 patients were analysed. Two hundred and three of these patients (67.2%) received monotherapy. The most commonly used drugs were tetracyclines (39.7% of patients) (120/302) and cotrimoxazole (35.4% of patients) (107/302). SAT was considered successful in 58.6% (177/302) of the patients (median time administered, 36.5 months; IQR 20.75-59.25). Infection was controlled in 50% of patients at 5 years according to Kaplan-Meier analysis. Resistance development was documented in 15 of 65 (23.1%) of the microbiologically documented cases. SAT failure was associated with age <70 years (sub-hazard ratio (SHR) 1.61, 95% CI 1.1-2.33), aetiology other than Gram-positive cocci (SHR 1.56, 95% CI 1.09-2.27) and location of the prosthesis in the upper limb (SHR 2.4, 95% CI 1.5-3.84). SAT suspension was necessary due to adverse effects in 17 of 302 patients (5.6%). CONCLUSIONS: SAT offers acceptable results for patients with PJI when surgical treatment is not performed or when it fails to eradicate the infection.

Targeting only reverse transcriptase with zidovudine/lamivudine/abacavir plus tenofovir in HIV-1-infected patients with multidrug-resistant virus: a multicentre pilot study.

OBJECTIVES: To evaluate the safety, immunological outcome and HIV-1 evolution in the reverse transcriptase (RT) in patients with multidrug resistance receiving zidovudine/lamivudine/abacavir (TZV) plus tenofovir (TDF). METHODS: Pilot analysis of highly experienced patients (n=28), with > or =1 thymidine-associated mutation (TAM) and the M184V mutation. RESULTS: Median of 8.5 treatment regimens, 58% Centers for Disease Control stage C. Baseline (nadir) CD4 count 363 (112) cells/microL. There was a sustained 24-week drop in viral load (VL) of 0.71 HIV-1 RNA copies/mL (P<0.001), with 35.7% (10/28) achieving a VL of <50 copies/mL. The median 24-week decrease in CD4 was -53 cells/microL and only-17 cells/microL when baseline CD4 was <350 cells/microL. There was no evolution in RT mutations, TAMs, accessory mutations or K65R. No clinical progression and one out of 28 suspected abacavir Hypersensitivity Reaction (HSR). Lower probability of achieving VL<400 copies/mL was associated with D67N (P=0.007), D67N/M41L (P=0.01), > or =3 TAMs (P=0.07) and VL>10 000 copies/mL (P=0.01). Mutations conferring zidovudine hypersusceptibility (Y181C, K65R and L74V) did not improve virological or immunological outcomes. Better CD4 outcomes were seen in patients without M41L (P=0.04) or with baseline VL<10,000 copies/mL (P=0.01). CONCLUSIONS: A bridging regimen with TZV+TDF prevents significant immunological decline and may forestall viral evolution in HIV-1 RT despite persistent viral replication.

Incidence and risk factors for tuberculosis in HIV-positive subjects by HAART status.

OBJECTIVE: To estimate incidence rates and risk factors for tuberculosis (TB) in human immunodeficiency virus seroprevalent subjects. METHODS: Multicentre, hospital-based cohort study of patients presenting to 10 Spanish hospitals from 1 January 1997 to 31 December 2003. Poisson regression was used and highly active antiretroviral treatment (HAART) was modelled as a time-dependent covariate. RESULTS: A total of 4268 patients were followed for a median of 3.8 years; 221 TB cases were diagnosed over 16 464 person-years (py). TB rates were higher in HAART-naïve subjects (1.56 per 100 py, 95%CI 1.36-1.79) than those on HAART (0.5/100 py, 95%CI 0.31-0.80). Among HAART-naïves, TB risk factors were: being male, being an injecting drug user (IDU) (RR 2.01, 95%CI 1.28-3.16), having low CD4 counts (P < 0.001) and high viral loads (P < 0.001). HAART was protective (RR 0.26, 95%CI 0.16-0.40) and reductions in TB rates were observed in the last calendar period (RR 0.74, 95%CI 0.55-1.00). For patients on HAART, no differences were observed by category of transmission. Low CD4 counts at entry were associated with higher TB rates (P < 0.001). CONCLUSIONS: HAART was associated with lower TB rates, and TB risk factors differed according to whether or not patients had received HAART. To further reduce TB rates, additional strategies are needed, such as timely access and adherence to HAART, especially in IDUs.

Prevalence of M. tuberculosis infection and tuberculosis disease among HIV-infected people in Spain.

OBJECTIVE: To study the prevalence of Mycobacterium tuberculosis infection (MTBI) and past/current tuberculosis (TB) among human immunodeficiency virus (HIV) infected persons in Spain. DESIGN: Longitudinal study conducted between 2000 and 2003 at 10 HIV hospital-based clinics. Data were drawn from clinical records. Associations were measured using odds ratios (ORs) and their 95% confidence intervals (95%CI). RESULTS: Of the 1242 persons who met the eligibility criteria, most were male (75%), aged <40 years (75%) and unemployed (40%). HIV infection occurred through intravenous drug use (53%), heterosexual sex (29%) and sex between men (16%). In the initial evaluation, 315 subjects had evidence of MTBI: 84 (6.8%) had a history of TB, 23 (1.8%) current TB and 208 (16.8%) latent tuberculosis infection (LTBI). MTBI was associated with male sex, age 30-49 years, contact with a TB case, homelessness, poor education, and negatively with CD4 <100 cells/mm(3). Among subjects with MTBI, past/current TB was associated with retirement/disability (OR 6, 95%CI 1.6-22.5), CD4 <200 cells/mm(3) (OR 9.7, 95%CI 3.8-24.6), viral load >55,000 copies (OR 5.3, 95%CI 1.4-20.0), and negatively, with skilled work (OR 0.4, 95%CI 0.1-1.0) or administrative/managerial/professional work (OR 0.05, 95%CI 0.01-0.4). CONCLUSION: Social context has an impact on the effectiveness of HIV and TB control programmes even in industrialised countries with free access to health care.

Use of cohort data to estimate national prevalence of transmitted drug resistance to antiretroviral drugs in Spain (2007-2012).

Prevalence of transmitted drug resistance (pTDR) to antiretroviral drugs in Spain (2007-2012) was estimated using the CoRIS cohort, adjusting its territorial distribution and transmission route to the reference population from the Spanish Information System on New human immunodeficiency virus diagnoses. A total of 2702 patients from ten autonomous communities and with naive FASTA sequence within 6 months of human immunodeficiency virus diagnosis were selected. Weighted pTDR, estimated using the inverse probability of selection in the sample by autonomous communities and transmission group, was 8.12% (95% CI 6.44-9.80), not significantly different from unweighted pTDR. We illustrate how proportional weighting can maximize representativeness of cohort-based data, and its value to monitor pTDR at country level.

Increased risk of non-AIDS-related events in HIV subjects with persistent low CD4 counts despite cART in the CoRIS cohort.

The aim was to analyze clinical complications in HIV-infected subjects who persistently maintain low CD4 levels despite virological response to cART in the Spanish CoRIS cohort. The main inclusion criteria were CD4 counts <200cells/mm(3) at cART-initiation and at least 2years under cART achieving a viral load <500copies/mL. Those patients with CD4 counts <250cells/mm(3) 2years after cART were classified as the Low-CD4 group, and clinical events were collected from this time-point. Poisson regression models were used to calculate incidence rate ratios of death, AIDS-defining events, serious non-AIDS-defining events (NAE) and of each specific NAE category (non-AIDS-defining malignancies (non-ADM), cardiovascular, kidney- and liver-related events). Of 9667 patients in the cohort, a total of 1128 met the criteria and 287 (25.4%) were classified in the Low-CD4 group. A higher risk of death (aIRR: 4.71; 95% CI: 1.88-11.82; p-value=0.001) and of non-ADM were observed in this group (aIRR: 2.23; 95% CI: 1.07-4.63; p=0.03). Our results stress the need to control accelerated aging in this population to counter their increased risk of non-AIDS-defining diseases, particularly cancer, and are consistent with the concept that clinical complications are potentially affected by genetics and lifestyle.

[Bilateral lung reduction by video-assisted thoracoscopy in a patient with non-bullous pulmonary emphysema and laryngeal neoplasia]. / Neumorreducción bilateral por videotoracoscopia en un paciente con enfisema pulmonar no bulloso y neoplasia laríngea.

Lung reduction has been show to be a promising treatment for the final phases of non-bullous pulmonary emphysema. The role of video-assisted thoracoscopy (VAT) in this disease has not yet been established. We report a case of bilateral non-bullous pulmonary emphysema in which transplantation was ruled out because of laryngeal neoplasm treated three months earlier. Using VAT, we performed bilateral lung reduction in the apical zones with good therapeutic results. We find that in patients reduction by VAT, although not a curative treatment, leads to immediate postoperative improvement in lung function and dyspnea, and does not exclude the possibility of later performing lung transplantation.

[Pulmonary cavitation lesions in patients infected with the human immunodeficiency virus: an analysis of a series of 78 cases]. / Lesiones pulmonares cavitadas en los pacientes infectados por el virus de la inmunodeficiencia humana: análisis de una serie de 78 casos.

BACKGROUND: To assess the clinical, radiologic and microbiological features of lung cavitation and HIV infection. Evaluation of the differences related to this disease in the last years. PATIENTS AND METHODS: Retrospective review of all patients with lung cavitation and HIV infection admitted at our hospital from January 1989 until December 1994 and prospective study of all patients with the same characteristics during 1995 and 1996. Lung cavitation was defined as any parenchymal lesion, with air content, visible in a simple X-ray and greater than 1 cm of diameter. Criteria for confirmed, probable or possible diagnosis were defined. RESULTS: 78 cases of lung cavitation have been identified in 73 patients. The radiologic patterns included unilobar and multilobular involvement in 31 and 47 cases, respectively. Cavities were multiple and single in 40 and 38 cases respectively. Findings with fine needle aspiration biopsy (FNAB) were diagnostic in 11 out of 14 cases. A clinical diagnosis was performed in all 78 cases, with microbiological results in 69 cases (88.5%): Mycobacterium tuberculosis in 20, Pneumocystis carinii in nine, Pseudomonas aeruginosa in nine, Staphylococcus aureus in eight (5 endocarditis with cavitary septic emboli), Rhodococcus equi in six, P. aeruginosa and S. aureus in three, Salmonella enteritidis in three, Cryptococcus neoformans in two, Aspergillus fumigatus in two and others in 7 cases. Confirmed, probable and possible diagnosis was considered in 54, 15 and 9 cases, respectively. Thirteen episodes of spontaneous pneumothorax were found. CONCLUSIONS: The lung cavitation rate is low, compared with the number of admissions related to HIV infection; nevertheless, many of them are in close relationship with HIV infection, and most of them are caused by treatable infections. It is important to know the clinical and radiological characteristics, in order to establish an early diagnosis and an appropriate therapy. Pseudomonas aeruginosa is becoming an important cause of lung cavitation. In our series, spontaneous pneumo-thorax was not related to Pneumocystis carinii pneumonia in 61.5% of cases.

[The usefulness of the desensitization to rifampin in the treatment of mycobacterial disease in patients with AIDS]. / Utilidad de la desensibilización a rifampicina en el tratamiento de enfermedades producidas por micobacterias en pacientes con SIDA.

BACKGROUND: Hypersensitivity reactions to rifampin are relatively uncommon, but they may result in cessation of therapeutic medications. PATIENTS AND METHODS: We report our experience with oral desensitization protocol to rifampin in a group of 35 HIV-positive patients with mycobacterial disease who had some hypersensitivity reaction to this drug. RESULTS: Adverse reactions with this protocol were few and easily treated. CONCLUSIONS: Oral desensitization to rifampin is safe and effective, allowing some of these patients (60%) to reintroduce the drug and to reduce the time of treatment.

[Good response to azidothymidine in 3 patients with vacuolar myelopathy]. / Buena respuesta a azidotimidina en tres pacientes con mielopatía vacuolar.

We report 3 drug abusers with human immunodeficiency virus (HIV) infection who had presented with myelopathic symptoms. A diagnosis of vacuolar myelopathy associated with HIV was made. The patients had a favorable response to azidothymidine. They were followed up as outpatients, and they showed a significant clinical improvement within 1-3 months of therapy. They remained stable 11 months afterwards. The patients with this type of disease may benefit from azidothymidine therapy.

[Pulmonary Kaposi's sarcoma in a heterosexual parenteral drug addict patient with the acquired immunodeficiency syndrome]. / Sarcoma de Kaposi pulmonar en un paciente heterosexual adicto a drogas por vía parenteral con síndrome de inmunodeficiencia adquirida.

A case of Kaposi syndrome is described in a 28-year-old heterosexual male with acquired immunodeficiency syndrome. The disease began clinically with pulmonary disease, without mucocutaneous lesions. This form of presentation is extremely infrequent and has not been described in non-homosexual subjects. Clinical manifestations were fever, cough and dyspnea. Thoracic radiography observed a perihilar interstitial pattern which evolved to a bilateral nodular pattern with perihilar adenopathy. There was endobronchial disease, however pulmonary biopsy was required for diagnosis. Complete tumoral remission was achieved with adriamycin, bleomycin and vincristine.

[Enteral nutrition in ICU patients on a high-protein diet]. / Nutrición enteral en pacientes de UCI con dieta hiperproteica.

BASIS: The need for nutritional support is at present beyond question, while the use of early enteral nutrition in critical patients admitted to Intensive Care Units is increasingly common and would appear to offer a set of advantages as nutritional support. PATIENTS: Of a total of 26 consecutive enteral nutrition patients, 22 were studied prospectively (84.6%), and, through a nasal-gastric probe, were administered early high protein enteral polymeric diet with 25% of total calorific value from proteins, for an average of 10 days. The other four (15.4%) did not enter the study, according to the exclusion criteria established, and so were not taken into account in the statistics. METHOD: A design was followed in which the diet was administered progressively until reaching 30 ml/kg/day, in a maximum of three days, during which aspects were analyzed dealing with tolerance and ease of use, on the one hand, and other metabolic and nutritional aspects on the other. Analytical controls were carried out on days 0, 4, 8 and 12. Tolerance and adverse effects were monitored continuously. RESULTS: During the study, one of the twenty-two patients died (4.54%): the other 21 remained alive. In analysis of the metabolic and nutritional parameters, improvement was obtained in all those expected to reach normal levels, with p < 0.001 (glucose, prealbumin, TF, RBP, Zn, Mg and P). Of particular note was the evolution of the nitrogen balance (p < 0.001 and r = 0.77). As to tolerance, diarrhea appeared in two patients (9.09%), ileus in one (4.5%): no cases were detected of abdominal distension, nausea or vomiting. In no case was diet suspended for causes attributable to the enteral nutrition, nor was any therapeutic manipulation required. CONCLUSIONS: Excellent tolerance of enteral nutrition was obtained, with almost no complications associated with its use, despite the gravity of the patients (APACHE 14). On the other hand, an improvement was obtained in metabolic and nutritional parameters, with the particular significance of the nitrogen balance.

AIDS-associated cholangiopathy in a series of ten patients.

OBJECTIVE: To present the clinical, biological, radiologic and cholangiographic findings in patients with clinical suspicion of AIDS associated cholangiopathy in our hospital. PATIENTS AND METHODS: We have revised the clinical charts of 10 patients admitted in our hospital from 1991 to 1995. RESULTS: Ultrasonography and/or abdominal CT were carried out on all the patients. Biliary tract dilatation was observed in 11 cases. From the 12 ERCP, biliary tract was fulfilled in 11. In 5 cases papillary stenosis was diagnosed, sclerosing cholangitis in 2, normal biliary tract in 3 and acute cholangitis in one case. Sphincterotomy was done in 5 patients, with clinical improvement. In one case, another sphincterotomy was needed because of reestenosis. CONCLUSIONS: ERCP is very important in the diagnosis of AIDS associated cholangiopathy. Endoscopic sphincterotomy relieves abdominal pain in these patients. Cholangiopathy occurs in very immunocompromised HIV positive patients. Survival is very short.

[Role of specialized care services of the national health service in the new framework for the prevention of occupational risks (I)]. / Papel de los servicios de Atención Especializada del Sistema Nacional de Salud en el nuevo marco de la prevención de riesgos laborales (I).

INTRODUCTION: The Spanish constitution and other legal provisions reflect the need to guarantee the health and security of workers at work. The Prevention of Industrial Risks Act incorporates this mandate and suggests a new model of prevention based on continued control of risk, participation of the workers and their education, and different modes of prevention management are set out. DEVELOPMENT: The objective of occupational medicine covers four areas: environment (evaluation of posts, teams, dangerous substances, etc.), health (vigilance of professional illness), emergencies and information and documentation (confidentiality). At present the task of the occupational doctor is hampered by (a) The polarization of prevention: the effort to reduce the high rate of accidents and permissiveness with regard to professional illness. (b) Complementary investigations: the lack of specialist reference services which supervise the health of the workers. (c) Minimal development in small and medium size businesses: The National Health System phagocytes industrial diseases, erroneously labelled as ordinary illness. CONCLUSIONS: (1) The medical training of all specialists should include a period dedicated to the study of occupational diseases and work as a source of health problems. (2) To improve the coordination between the occupational doctor and the Primary Care doctor, the creation of specialist reference services for occupational illnesses, by means of the National Health Service or the Mutual Aid Societies of occupational accidents and professional illnesses so as to refer suspected cases to them. (3) To emphasize the clinical history, evaluating the principle of Hipocrates. (4) To take into account sentry pathology in conditions of unknown origin. (5) To make a specific control of the health of all workers, particularly those who work with dangerous products or substances.

[Training in social skills in patients with acquired brain damage]. / Entrenamiento en habilidades sociales en pacientes con daño cerebral adquirido.

INTRODUCTION: Brain damaged patients have cognitive deficits, behaviour disorders and personality changes which affect socio-familial behaviour. Frequently, these changes generate considerable disturbance between family members and make it very difficult to return to work. OBJECTIVE: We describe a pilot study which led to the development and application of a focal rehabilitation programme aimed at retraining this group in social skills. PATIENTS AND METHODS: The programme was intensive (3 months) and included 6 outpatients (5 men and 1 woman) who took part in programmes of neuropsychological rehabilitation after traumatic or vascular cerebral lesions (X = 19.2 months after the lesion occurred). The average age of the patients was 27.2 years and their average IQ 109.2. Individual and group interventions were combined (role-playing, 'make-believe' work, video filming) emphasizing particularly the processes of learning without making mistakes and the extension of achievements to the natural setting (controlled trials). RESULTS AND CONCLUSIONS: We state and describe the relationship between the nature of neuropsychological and psychopathological deficits, and the characteristics of the limitations in social behaviour. The patients showed a significant reduction in the level of anxiety and aggressive behaviour and improvement in consciousness of their defects. Some improvement was seen in expressing opinions and emotions, and in ability to adapt social conduct to different situations (flexible behaviour). Finally we describe the conclusions drawn as to this treatment for future review and improvement of the programme.